II. Mechanism

  1. Sedative hypnotic
    1. Potentiates gamma-aminobutyric acid receptors
  2. No Analgesic effect
    1. Administer concurrent Analgesics (typically given 20-30 minutes prior to Propofol start)
  3. Drug Abuse potential (especially among anesthesiologists, nurse anesthetists, emergency medicine staff, dentists)
    1. Increases Dopamine levels which may reinforce addiction
    2. Increases Serotonin levels which may be Hallucinogenic
    3. References
      1. Majoewsky (2012) EM:RAP 12(1): 3

III. Precautions

  1. Propofol has no Analgesic effect, and therefore Opioid Analgesics are often used before Propofol
  2. Propofol (esp. with concurrent Opioids) increases the risk of cardiopulmonary depression (Hypoxia, Hypotension)
    1. Close monitoring is critical (second provider skilled in airway management is preferred)
    2. Consider pre-procedure crystalloid bolus of 500 ml (or 10-20 ml/kg)
    3. Consider oxygen via nasal canula at 2 L/min
    4. Suction, Bag-valve mask, Nasopharyngeal Airway, and intubation equipment should be ready for use
    5. Consider Capnography

IV. Pharmacokinetics

  1. Rapid onset and short half-life
  2. Lipid-soluble and crosses blood-brain barrier
  3. Onset: 30-45 seconds (<1 minute)
  4. Duration: 6 minutes on average (5 to 15 minutes, prolonged with repeated dosing)
  5. Lipid emulsion bottle is at risk of Bacterial contamination and growth once accessed
    1. Discard any open bottles after 12 hours

V. Preparation

  1. See Procedural Sedation
  2. Second provider skilled in airway management (preferred)
  3. Preventive measures
    1. Pre-procedure crystalloid bolus of 500 ml (or 10-20 ml/kg)
    2. Oxygen via nasal canula at 2 L/min
    3. Opioid Analgesics given at least 20 minutes before procedure
  4. Monitoring Equipment
    1. Pulse Oximetry (Oxygen Saturation and Heart Rate)
    2. Blood Pressure cuff, manual or automatic cycled every few minutes
    3. Consider Capnography
  5. Emergency Equipment
    1. Wall Suction (typically with yanker catheter tip)
    2. Bag-valve mask
    3. Nasopharyngeal Airway
    4. Intubation equipment (see Advanced Airway)

VI. Dosing: Adults

  1. Deep Sedation (not FDA approved)
    1. Adult (preferred procedural sedative)
      1. Initial: 1 mg/kg IV over 20-30 seconds (typically given as smaller increments)
      2. Next: 0.5 mg/kg IV as needed every 3 minutes
      3. Decrease dose in older patients
    2. Child
      1. Initial: 1 mg/kg IV (up to 40 mg) over 20-30 seconds (typically given as smaller increments)
      2. Next: 0.5 mg/kg IV (up to 20 mg) as needed every 3 minutes
    3. Typically no respiratory depression at 1 mg/kg dose
      1. Amnesia occurs at this dose
    4. Perform painful procedures immediately following infusion
      1. Amnestic effect wears off prior to Sedation
  2. Intubation Sedation (not FDA approved)
    1. Dose 2 to 2.5 mg/kg IV over 20 to 30 seconds
  3. Ventilator Sedation in ICU
    1. Infusion: 5-50 mcg/kg/min
  4. Anesthesia
    1. Age under 55 years old
      1. Titration: 40 mg IV every 10 seconds until induction achieved
      2. Typical cummulative total dose: 2 to 2.5 mg/kg
      3. Maintenance infusion: 100-200 mcg/kg/min
    2. Age 55 years old or older
      1. Decrease dose from that list above for younger patients

VII. Dosing: Children

  1. Deep Sedation (not FDA approved)
    1. Dose 1 mg/kg IV (up to 40 mg maximum) over 20 to 30 seconds
    2. May repeat 0.5 mg/kg IV (up to 20 mg maximum) as needed
    3. Avoid for prolonged ICU use
  2. Anesthesia (age 3 years and older)
    1. Typical cummulative total dose: 2.5 to 3.5 mg/kg over 20-30 seconds
    2. Maintenance infusion: 125-300 mcg/kg/min

VIII. Indications

  1. Procedural Sedation and Analgesia (PSAA)
    1. Indicated for ASA Physical Status Score 2 (non-hypotensive, stable)
  2. Rapid Sequence Intubation
    1. Other agents (e.g. Etomidate, Ketamine) are preferred for emergency department induction (Hypotension risk)

IX. Contraindications

  1. Soy allergy
  2. Egg allergy

X. Adverse Effects

  1. Propofol Infusion Syndrome
  2. Cardiopulmonary adverse effects (reduced by administering with lower dose and slower titration)
    1. Respiratory depression
      1. Close monitoring by a second provider skilled in airway management is preferred
      2. Consider oxygen via nasal canula at 2 L/min
      3. Suction, Bag-valve mask, Nasopharyngeal Airway, and intubation equipment should be ready for use
      4. Consider Capnography
    2. Hypotension and myocardial depression
      1. Systolic Blood Pressure drops 10-18 mmHg, Diastolic Blood Pressure drops 10-16 mmHg
      2. Consider pre-procedure crystalloid bolus of 500 ml (or 10-20 ml/kg)
      3. Increase time (>20 minutes) between IV Opioids and Propofol
      4. Consider alternative sedatives (e.g. Etomidate or Ketamine) in hypotensive patients
      5. Phenylephrine may be used to counter the hypotensive effects of Propofol
  3. Overdose
    1. No antidote
    2. Manage with ABC Management and supportive care

XI. Safety

  1. No delay in Lactation
  2. Pregnancy category B
    1. However, minimal data available
    2. Not Teratogenic based on limited data

XII. References

  1. Acker, Koval and Leeper (2017) Crit Dec Emerg Med 31(4): 3-13

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Ontology: Propofol (C0033487)

Definition (CHV) a kind of short-acting anesthetic
Definition (NCI) A hypnotic alkylphenol derivative. Formulated for intravenous induction of sedation and hypnosis during anesthesia, propofol facilitates inhibitory neurotransmission mediated by gamma-aminobutyric acid (GABA). This agent is associated with minimal respiratory depression and has a short half-life with a duration of action of 2 to 10 minutes.
Definition (PDQ) A hypnotic alkylphenol derivative. Formulated for intravenous induction of sedation and hypnosis during anesthesia, propofol facilitates inhibitory neurotransmission mediated by gamma-aminobutyric acid (GABA). This agent is associated with minimal respiratory depression and has a short half-life with a duration of action of 2 to 10 minutes. Check for "http://www.cancer.gov/Search/ClinicalTrialsLink.aspx?id=461189&idtype=1" active clinical trials or "http://www.cancer.gov/Search/ClinicalTrialsLink.aspx?id=461189&idtype=1&closed=1" closed clinical trials using this agent. ("http://nciterms.nci.nih.gov:80/NCIBrowser/ConceptReport.jsp?dictionary=NCI_Thesaurus&code=C29384" NCI Thesaurus)
Definition (MSH) An intravenous anesthetic agent which has the advantage of a very rapid onset after infusion or bolus injection plus a very short recovery period of a couple of minutes. (From Smith and Reynard, Textbook of Pharmacology, 1992, 1st ed, p206). Propofol has been used as ANTICONVULSANTS and ANTIEMETICS.
Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH D015742
SnomedCT 387423006, 74674007
LNC LP31828-4, MTHU015674
English Disoprofol, Propofol, 2,6 Diisopropylphenol, 2,6-Diisopropylphenol, Phenol, 2,6-bis(1-methylethyl)-, 2,6-Bis(1-methylethyl)phenol, propofol (medication), PROPOFOL, Propofol [Chemical/Ingredient], propofol, Propofol (product), Propofol (substance)
Swedish Propofol
Czech propofol
Finnish Propofoli
Russian DIZOPROFOL, PROPOFOL, ДИЗОПРОФОЛ, ПРОПОФОЛ
Japanese プロポホル, 2,6-ジイソプロピルフェノール, ジソプロホル, プロポフォール, ジソプロフォール
German BIS METHYLETHYL PHENOL 02 06 01, 2,6-Bis(1-Methylethyl)Phenol, Diisoprofol, Propofol
Polish Propofol
Spanish propofol (producto), propofol (sustancia), propofol, Disoprofol, Propofol
French Propofol
Italian Propofol
Portuguese Disoprofol, Propofol

Ontology: Diprivan (C0678120)

Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH D015742
English diprivan, Diprivan, Astra Brand of Propofol, AstraZeneca Brand of Propofol, Disoprivan, Zeneca Brand of Propofol